Peeling the onion: understanding others' lived experience.

Society and some healthcare professionals often marginalise pregnant women who take illicit substances. Midwives who care for these women are often viewed as working on the edge of society. This research aimed to examine the lived experiences of midwives who care for pregnant women who take illicit drugs. A phenomenological study informed by Heidegger, Gadamer and Merleau-Ponty was chosen to frame these lived experiences. Using face-to-face interviews, data were collected from 12 midwives making a difference, establishing partnerships and letting go and refining practice. Lived experiences are unique and can be difficult, intangible and couched in metaphor and difficult to grasp. This paper aims to discuss lived experience and suggests that like an onion, several layers have to be peeled away before meaning can be exposed; each cover reveals another layer beneath that is different from before and different from the next. The study provides exemplars that explain lived experiences.

Hermeneutic phenomenology: a methodology of choice for midwives.

Hermeneutic phenomenology has been used widely by researchers to understand lived experiences. This methodology asserts that individual people are as unique as their life stories. The practice of midwifery is underpinned by a philosophy that values women and the uniqueness of their child-bearing journey. The tenets of hermeneutics phenomenology align with those of contemporary midwifery practice, making it a useful research methodology for providing insights into issues relevant to the profession. The purpose of this paper is to unravel some foundational concepts of hermeneutic phenomenology and recommend it as a methodology of choice for midwives to apply to their application to midwifery-in-action.

Clinical decision-making: midwifery students' recognition of, and response to, post partum haemorrhage in the simulation environment.

BACKGROUND: This paper reports the findings of a study of how midwifery students responded to a simulated post partum haemorrhage (PPH). Internationally, 25% of maternal deaths are attributed to severe haemorrhage. Although this figure is far higher in developing countries, the risk to maternal wellbeing and child health problem means that all midwives need to remain vigilant and respond appropriately to early signs of maternal deterioration. METHODS: Simulation using a patient actress enabled the research team to investigate the way in which 35 midwifery students made decisions in a dynamic high fidelity PPH scenario. The actress wore a birthing suit that simulated blood loss and a flaccid uterus on palpation. The scenario provided low levels of uncertainty and high levels of relevant information. The student's response to the scenario was videoed. Immediately after, they were invited to review the video, reflect on their performance and give a commentary as to what affected their decisions. The data were analysed using Dimensional Analysis. RESULTS: The students' clinical management of the situation varied considerably. Students struggled to prioritize their actions where more than one response was required to a clinical cue and did not necessarily use mnemonics as heuristic devices to guide their actions. Driven by a response to single cues they also showed a reluctance to formulate a diagnosis based on inductive and deductive reasoning cycles. This meant they did not necessarily introduce new hypothetical ideas against which they might refute or confirm a diagnosis and thereby eliminate fixation error. CONCLUSIONS: The students response demonstrated that a number of clinical skills require updating on a regular basis including: fundal massage technique, the use of emergency standing order drugs, communication and delegation of tasks to others in an emergency and working independently until help arrives. Heuristic devices helped the students to evaluate their interventions to illuminate what else could be done whilst they awaited the emergency team. They did not necessarily serve to prompt the students' or help them plan care prospectively. The limitations of the study are critically explored along with the pedagogic implications for initial training and continuing professional development.

The decision-making processes adopted by rurally located mandated professionals when child abuse or neglect is suspected.

The reporting of suspected child abuse and neglect is a mandated role of medical doctors, nurses, police and teachers in Victoria, Australia. This paper reports on a research study that sought to explicate how mandated professionals working in rural Victorian contexts identify a child/ren at risk and the decisions they make subsequently.

Australian rural remote registered nurses' experiences of learning to provide antenatal services in general practice: a pilot study.

This article reports on a pilot vocational study programme for provision of antenatal services in the general practice environment. The concurrent evaluation study assessed practice nurses' experiences of undertaking the pilot programme, the level and applicability of the content, and the mode of delivery. General practitioners' understanding of the role of the nurse in providing antenatal services, and the actual and potential impact of this new role on models of service delivery and care were also investigated. Women receiving care from practice nurses within this new model of service delivery and care were also of interest in this study. Findings showed that the current role of the general practice nurse in caring for pregnant women is restricted to assisting the general practitioner to complete their assessment of clients. Organizing clinical placement with a midwife was a major barrier to completing the pilot programme.

Anti-CD20 monoclonal antibody (rituximab) therapy for acute cardiac humoral rejection: a case report.

Humoral or antibody-mediated rejection in cardiac transplant recipients is mediated by donor-specific cytotoxic antibodies and is histologically defined by linear deposits of immunoglobulin and complement in the myocardial capillaries. Antibody-mediated rejection often is accompanied by hemodynamic compromise and is associated with reduced long-term graft survival. Standard immunosuppression, designed to target T cell immune function, is largely ineffective against this B cell-driven process. Current treatment options for humoral rejection are limited by a lack of specific anti-B cell therapies. We present the case of a 50-year-old woman with hemodynamically significant humoral rejection resistant to steroids, cyclophos-phamide, and plasmapheresis who responded to the addition of anti-CD20 monoclonal antibody therapy (rituximab). One year posttransplant, the patient is rejection-free, with normal left ventricular systolic function and coronary arteries.

Midwives experiences of establishing partnerships: working with pregnant women who use illicit drugs.

OBJECTIVE: To present the interpreted experiences of midwives who choose to work with pregnant women who also use illicit drugs. DESIGN: Twelve (n=12) Australian midwives were interviewed. Each interview was audio-taped, de-identified and transcribed. The interviews were analysed using a systematic, thematic analysis approach informed by Heideggarian hermeneutic phenomenology. FINDINGS: Three themes identified from the data that encapsulate the experience were establishing partnerships, making a difference, and letting go and redefining practice. The interpretations of establishing partnerships which includes engagement, genuine regard and compassion, with a subtheme courting the system are presented in this paper. The midwives' experiences were both positive and negative, as they were rewarded and challenged by the needs of women who use illicit drugs and the systems in which they worked. CONCLUSION: The midwives in this study found that establishing partnerships was essential to their work. They appraised their experience of working with pregnant women who used illicit drugs and found strategies that attempted to meet the needs of the women, the system and themselves. The participants revealed that to support women and families who use illicit drugs in their community, partnerships must be based on deep respect and trust. Significant components engagement, genuine regard and compassion that are central to midwifery partnerships require revisiting to address the needs of this vulnerable population of women.

Exploring the impact of clinical placement models on undergraduate midwifery students.

BACKGROUND: Learning undertaken through clinical placements provides up to 50% of the educational experience for students in pre-registration midwifery courses. However little is known about of the impact various models of clinical placement have on the learning experiences of undergraduate midwifery students. Two clinical placement models have been employed for undergraduate midwifery students at Monash University, including the block placement model and the continuous two days per week model. OBJECTIVE: This project sought to explore the learning experiences of students in these two models of placement. METHOD: Focus groups were held on two campuses with a total of 17 students from different cohorts and programs. DISCUSSION: No one type of placement was favoured over another both had benefits and disadvantages. Further, this study found that regardless of program and clinical placement model the major learning impact for students was related to the midwife they worked with each day on placement rather than to the model. CONCLUSION: No one type of placement was favoured over another both had benefits and disadvantages. Further, this study found that regardless of program and clinical placement model the major learning impact for students was related to the midwife they worked with each day on placement rather than to the model.

Exploring Heideggerian hermeneutic phenomenology: a perfect fit for midwifery research.

BACKGROUND: Heideggerian hermeneutic phenomenology has been used widely to understand the meaning of lived experiences in health research. For midwifery scholars this approach enables deep understanding of women's and midwives' lived experiences of specific phenomena. However, for beginning researchers this is not a methodology for the faint hearted. It requires a period of deep immersion to come to terms with at times impenetrable language and perplexing concepts. OBJECTIVES: This paper aims to assist midwives to untangle and examine some of the choices they face when they first come to terms with an understanding of this methodology and highlights the methodology's capacity to reveal midwifery authenticity and holistic practice. DISCUSSION: The illumination of a selection of various concepts underpinning hermeneutic phenomenology will inform midwives considering this methodology as suitable framework for exploring contemporary midwifery phenomena.

Undergraduate midwifery students' sense of belongingness in clinical practice.

BACKGROUND: Clinical placements form a large and integral part of midwifery education. While much has been written about nursing students' clinical placements, less is known about clinical experiences of undergraduate midwifery students. In nursing, belongingness has been demonstrated to be a key factor in clinical learning but little is known about this in midwifery education. OBJECTIVES: This study sought to examine undergraduate midwifery students' sense of belongingness in their clinical practice. DESIGN: A quantitative design using an online questionnaire was employed. A tool adapted by Levett-Jones (2009a), and previously used with nursing students, was utilised to examine sense of belonging in undergraduate midwifery students. PARTICIPANTS: Sixty undergraduate midwifery students from two campuses at one Australian university participated in the study. Students were drawn from a single Bachelor of Midwifery degree and a double Bachelor of Nursing/Bachelor of Midwifery degree. METHODS: On completion of a scheduled lecture, students were invited by one of the researchers to participate in the study by completing the online questionnaire and the link provided. Data were analysed using descriptive statistics. RESULTS: Midwifery students generally reported similar perceptions of belongingness with previous studies on nursing students. However, a few differences were noted that require further exploration to fully understand. CONCLUSIONS: Midwifery students experienced a sense of belonging in their clinical placements. The findings contribute to understandings of the experiences for midwifery students and provide a foundation on which to develop future clinical placement experiences.

Managing women with acute physiological deterioration: student midwives performance in a simulated setting.

OBJECTIVE: Midwives' ability to manage maternal deterioration and 'failure to rescue' are of concern with questions over knowledge, clinical skills and the implications for maternal morbidity and, mortality rates. In a simulated setting our objective was to assess student midwives' ability to assess, and manage maternal deterioration using measures of knowledge, situation awareness and skill, performance. METHODS: An exploratory quantitative analysis of student performance based upon performance, ratings derived from knowledge tests and observational ratings. During 2010 thirty-five student, midwives attended a simulation laboratory completing a knowledge questionnaire and two video, recorded simulated scenarios. Patient actresses wearing a 'birthing suit' simulated deteriorating, women with post-partum and ante-partum haemorrhage (PPH and APH). Situation awareness was, measured at the end of each scenario. Applicable descriptive and inferential statistical tests were, applied to the data. FINDINGS: The mean total knowledge score was 75% (range 46-91%) with low skill performance, means for both scenarios 54% (range 39-70%). There was no difference in performance between the scenarios, however performance of key observations decreased as the women deteriorated; with significant reductions in key vital signs such as blood pressure and blood loss measurements. Situation, awareness scores were also low (54%) with awareness decreasing significantly (t(32)=2.247, p=0.032), in the second and more difficult APH scenario. CONCLUSION: Whilst knowledge levels were generally good, skills were generally poor and decreased as the women deteriorated. Such failures to apply knowledge in emergency stressful situations may be resolved by repetitive high stakes and high fidelity simulation.